Active NPI
Susan F Mickel, M.D., PH.D.
- Neurology Physician
- Racine, WI
National Provider Identifier
1356441018
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Neurology Physician
- License
- 28735
- Practice address
- 1717 Taylor Ave
Racine, WI 53403-2405 - Phone
- (262) 638-6744
- Fax
- (262) 638-6540
- NPI assigned
- Sep 23, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Neurology Physician | 2084N0400X | 28735 | WI | Primary |
| Psychologist | 103T00000X | 3113-57 | WI |
Addresses
Primary practice location
1717 Taylor Ave
Racine, WI 53403-2405
Mailing address
1717 Taylor Ave
Racine, WI 53403-2405
Phone (262) 638-6744
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1356441018 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine, Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3113-57 | WI | MD | Psychologist |
| 28735 | WI | MD | Neurology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158969600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1377129600000",
"number": "1356441018",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1717 TAYLOR AVE",
"city": "RACINE",
"state": "WI",
"postal_code": "534032405",
"telephone_number": "262-638-6744",
"fax_number": "262-638-6540"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1717 TAYLOR AVE",
"city": "RACINE",
"state": "WI",
"postal_code": "534032405",
"telephone_number": "262-638-6744",
"fax_number": "262-638-6540"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MICKEL",
"first_name": "SUSAN",
"middle_name": "F",
"credential": "M.D., PH.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-09-23",
"last_updated": "2013-08-22",
"status": "A"
},
"taxonomies": [
{
"code": "2084N0400X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Neurology",
"state": "WI",
"license": "28735",
"primary": true
},
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "WI",
"license": "3113-57",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1356441018",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Racine, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.